CSPMS UKEdition 1/2015Introduction
Core Standards for Pain Management Services in the UK (CSPMS UK)
Introduction
Aims
This document is a collaborative multi-disciplinary publication providing arobust reference source for the planning and delivery of Pain Management Services in the United Kingdom. It is designed to provide a framework forstandard setting in the provision of Pain Management Services for healthcare professionals, commissioners and other stakeholdersto optimise the care of our patients. It is a document that will evolve and cannot be viewed as definitive at this stage but it will provide a firm foundation for the future.
Background
Pain clinics were initially developed in the late 1940s as services to help patients with cancer pain when there was widespreadprofessional reluctance to prescribe opioids. These were largely run by anaesthetists who excelled in the blockade of nerves with local anaesthetic ortheir destruction with neurolytic solutions. It soon became apparent howeverthat there was a societal need for health care professionals to improve their management of people with persistent non-cancer pain, as well as those with cancer pain. Over time there was a realisation that methods used to treat cancer pain were less effective in non-cancer pain and so the focus of services began to change. Clinicsbecame multi-professional, with physiotherapists, nurses, and clinical psychologists and others becomingkey members of the team. Pain Relief Clinics became Pain Management Clinics as the focus of care also incorporated management strategies for patients where their persistent pain was not seen as curable. In 1975, themultidisciplinary International Association for the Study of Pain (IASP) was created as an organisation devoted to the study of pain mechanisms and management of acute, chronic and cancer pain. The Intractable Pain Society of Great Britain and Ireland, was founded in 1967 by consultant anaesthetists for patients suffering pain. With advancing recognition of the multidisciplinary nature of pain management, it became a multi-professional organisation and was renamed ' The Pain Society' in 1988, while also becoming a chapter of IASP. From these beginnings, The British Pain Society emerged in 20041, when the Irish Pain Society formed its own Chapter of IASP. In 2007, the Faculty of Pain Medicine was established within the Royal College of Anaesthetists (RCoA). Fellowship of the Faculty was initially gained by undertaking an Advanced Pain Training year. In 2011, the Fellowship examination was introduced to ensure that anaesthetists who wished to practice Pain Medicine completed a specified training and attained an agreed training standard. Consultants in Pain Medicine in the United Kingdom are expected to demonstrate completion of training as determined by or equivalent to the Faculty of Pain Medicine (FPM) Advanced Pain Training criteria2.
This evolution in theprofessionalisation of pain medicine and pain management over the last decades has been accompanied by ongoing changes to the NHS across the four nations of the United Kingdom. The recognition of pain as a frequently undertreated condition of epidemic proportions has gradually worked its way into the consciousness of politicians and policy makers. As early as 2009, the then Chief Medical Officer, Sir Liam Donaldson recognised chronic pain as a public health issue and recommended that ''Agencies involved in the management of patients with chronic pain should form local pain networks to work together to improve the quality of local services3.'' Major developments and initiatives followed, including The English Pain Summit (2011), the National Pain Audit (2010-2012), development of The British Pain Society’s Map of Medicine Chronic Pain pathways (2013) and on part of the RCoA,the Chapters on Acute and Chronic Pain in the ''Guidelines for the Provision of Anaesthetic Services''document(GPAS-2014).
National Health Service England is working towards a '' House of Care'' model in the management of patients with persistent pain, including healthcare efforts ''at steps towards ensuring self management''. This includes ''developing practical tools and commissioning guidance to support the delivery of the Mandate commitment for everyone with a long term condition being offered a personalised care plan by April 2015''4. The recognition of the need for pain management services to provide a valuable contribution to the health and wellbeing of patients is occurringagainst the backdrop of devolution of health care across the four nations, and a universal concern about rising costs of health care.
The changing face of the NHS and rising patients’ expectations is driving aneed for change in the way that pain management services are organised and commissioned2. Services are expected to be centred around people. Traditional roles and practices may not produce the savings required and efficiencies may have to be made through service redesign. This offers opportunities for different ways of working for patient benefit. Integrated primary and secondary pain management services are seen as optimalin the emerging NHS landscape5. The national differences in providing such integration are acknowledged.
Agreement of professionals and users of pain management services towards a shared and common set of professional standards and associated recommendations has never seemed more urgent. This document will be of particular relevance to all relevant stakeholders including healthcare professionals, hospital managers, commissioners involved in management and the design of pain management services in primary care, the community, and specialist and specialised services within the hospital setting.
The publication of the first edition of Core Standards for Pain Management Services is a key part of an evolutionary journey to build a comprehensive index of recommendations and standards for Pain Management Services in the United Kingdom. Core Standards will be updated as the evidence base develops further. We acknowledge that in a number of areas, particularly those dealing with service configuration, the current evidence base is incomplete. The Faculty of Pain Medicine and the British Pain Society are addressing this ‘evidence gap’ and NICE have agreed that Pain Management is on the list of Quality Standards and there is ongoing work on this to strengthen the authority of our recommendations.
Content
The CSPMS UKdocument is divided into nine chapters, covering the following areas:
- Chapter One : Introduction
- Chapter Two: Commissioning of services
- Chapter Three: Description of services
- Chapter Four : Physical facilities for the delivery of pain management services
- Chapter Five: Pain management service team
- Chapter Six: Patient pathways
- Chapter Seven: Pain interventions
- Chapter Eight: Education , appraisal and revalidation
- Chapter Nine : Service improvement , clinical governance and research
Process
The CSPMS UK document has been designed so that its constituent chapters and sections have been written by respected UK professionals and lay representatives. The document has been subject to review by the Professional Standards Committee and the Board of the Faculty of Pain Medicine, and then sent out for wide stakeholder consultation. In the preparation of this document we have consulted with and sought representation from UK organisations and professional bodies linked to Pain Management.
Each guidance chapter will have the agreed format of Introduction, Standards, Recommendations, Background, References and Relevant Ongoing Research (where appropriate).
Standardsmust be followed. Standards aim to represent current best practice in pain management as published in relevant literature and/or agreed by a body of experts.
Recommendations will be statements that the authors feel should be routine practice in UK Pain Management. For services where Recommendations are not currently met there should be a clear strategy to meet these as soon as possible.
Guidance documents of this type should be seen as work in progress. With regard to the clinical Recommendations and Standards, the material presented does not in any sense obviate the need for experienced clinical judgement exercised by individual practitioners acting in the best interest of their patients. Moreover, the guidance should not in any way inhibit the freedom of clinical staff to determine the most appropriate treatment for any patient they are asked to manage in a particular place at a particular time. The reader should take into account these qualifying comments when applying CSPMS UK’sRecommendations and Standards.
For many pain managementservices across the UK (especially in geographically more remote settings) some of the Recommendations and Standards (particularly those describing staffing) may require a major reorganisation of healthcare delivery and will require time for implementation because of practical constraints such as workforce shortages. When such constraints exist, it is important that these services work closely with local commissioners to agree an appropriate action plan.
References
- The British Pain Society.About us. 2015.
- Faculty of Pain Medicine of the Royal College of Anaesthetists. Deans Statement, 2014.
- Department of Health. 150 years of the Annual Report of the Chief Medical Officer: On the state of public health 2008.
- Lords Hansard,Parliamentary question by Lord Luce, 13th May 2014
- Royal College of General Practitioners.Pain Management Services: Planning for the Future - Guiding clinicians in their engagement with commissioners. Royal College of General Practitioners, London. 2013.
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CSPMS UKEdition 1/2015Contents
Contents
Chapter 2 Commissioning of Services across the UK
2.1England
2.2Wales
2.3Scotland
2.4Northern Ireland
Chapter 3 Description of Service
3.1Population Needs of People in Pain attending Specialist Pain Services in the UK
3.2Access to Pain Management Services
3.3Pain Management Services in the Community
3.4Pain Management in the Secondary Care Setting including specialist services
3.5Pain Management in the Specialised Services
3.6Acute Pain Service
3.7Outcomes
Chapter 4 Physical Facilities
4.1Consultation / Assessment Facilities
4.2Equipment & Monitoring (incl. equipment safety and training)
Chapter 5 Pain Services Team
5.1Definition, Membership & Interaction of the Multidisciplinary and Multispecialty Team
5.2.1Consultants
5.2.2Trainees Lucy Miller
5.2.3Staff and Associate Specialist Grades and Specialty Doctors
5.3General Practitioners
5.4Nurses
5.5Occupational Therapists
5.6Pharmacy Services
5.7Pain Management Physiotherapists
5.8Psychologists
Chapter 6 Patient Pathways
6.1First Consultation, Follow-up and Discharge
6.2Communication with Patients
6.3Chronic (Non Cancer) Pain
6.4Adult Acute Pain Management
6.5 Cancer Pain
6.6.1Paediatric Acute Pain
6.6.2Paediatric Procedural Pain
6.6.3Paediatric Chronic Pain
Chapter 7 Pain Interventions
7.1Pain Management Programmes and Pain Rehabilitation
7.2Medicines Roger Knaggs
7.3Interventional Techniques in Pain Management
7.4Cancer Pain Interventions
Chapter 8 Education, Appraisal and Revalidation
8.1Continuing Professional Development
8.2Assessment of competence
8.3Appraisal
8.4Revalidation
Chapter 9 Service Improvement and Clinical Governance
9.1Quality Improvement
9.2aSafety: Never Events
9.2bSafety: Safeguarding
9.2Research & Development
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CSPMS UKEdition 1/2015Commissioning of Services
Chapter 2Commissioning of Services across the UK
2.1England
Beverly Collett and Andrew Baranowski
BACKGROUND
NHS England has decided to put ‘high quality care for all’ central to its purpose. Quality means safe, effective care with a positive patient experience. Effective care is about preventing premature mortality, enhancing the quality of life for people with long term conditions and helping people to recover from episodes of acute care or trauma.
This is the derivation of the outcomes framework for the NHS in England. By focusing on outcomes and especially patient experience, issues that have often been marginalised or neglected in the past can be given the attention they deserve. This is why for Domain 2 of the outcomes framework, Enhancing the Quality of Life for People with Long Term Conditions1, the House of Care has been adapted and adopted as a model to support person centred care.
The NHS in England is also facing significant financial challenges. To improve overall efficiency, it is planned to redesign services based on need, which add value and are patient centred and decommission services which are not seen to be clinically effective.
OPERATIONAL STRUCTURE FOR COMMISSIONING OF SERVICES2
The Secretary of State for Health
The Secretary of State for Health has ultimate responsibility for the provision of a comprehensive health service in England, and ensuring the whole system works together to respond to the priorities of communities and meet the needs of patients.
The Department of Health
The Department of Health (DH) is now responsible for strategic leadership of both the health and social care systems, but is no longer the headquarters of the NHS, nor will it directly manage any NHS organisations.
NHS England (Formerly established as the NHS Commissioning Board inOctober 2012).
NHS England isan independent body, at arm’s length to the government. Its main role is to improve health outcomes for people in England. It:
- provides national leadership for improving outcomes and driving up the quality of care
- oversees the operation of CCGs
- allocates resources to CCGs
- commissions primary care and specialised services
Clinical commissioning groups (CCGs)
Primary care trusts (PCTs)usedtocommission most NHS services and controlled 80% of the NHS budget. On April 1 2013, PCTs were abolished and replaced with clinical commissioning groups (CCGs). CCGshave takenon many of the functions of PCTs and in addition some functions previouslyundertaken by theDH.
All GP practicesnowbelongto a CCG. CCGs have multiprofessional membership and formal patient representation. CCGscommission most services, including:
- planned hospital care
- rehabilitative care
- urgent and emergency care (including out-of-hours)
- most community health services
- mental health and learning disability services
CCGs can commission any service provider that meets NHS standards and costs. These can be NHS hospitals, social enterprises, charities, or private sector providers.
However, they must be assured of the quality of services they commission, taking into account both National Institute for Health and Care Excellence (NICE) guidelines and the Care Quality Commission's (CQC) data about service providers.
BothNHS Englandand CCGs have a duty to involve their patients, carers and the public in decisions about the services they commission.
Health and Wellbeing Boards
Every "upper tier" local authority is establishing a Health and Wellbeing Board to act as a forum for local commissioners across the NHS, social care, public health and other services. The boards are intended to:
- increase democratic input into strategic decisions about health and wellbeing services
- strengthen working relationships between health and social care
- encourage integrated commissioning of health and social care services
Public Health England
A new organisation has been created: Public Health England (PHE), which provides national leadership and expert services to support public health, and also works with local government and the NHS to respond to emergencies. PHE:
- coordinates a national public health service and deliver some elements of this
- builds an evidence base to support local public health services
- supports the public to make healthier choices
- provides leadership to the public health delivery system
- supports the development of the public health workforce
Specialist Pain Management Services
These are commissioned by the CCGs. The CCGs have a statutory duty to improve the quality of services being commissioned by the NHS, in particular they have a duty to reduce health inequalities; pain services need to be prioritised in the same way as other long term conditions given its recognition decreed as such in 2012.
Pain management services should work within a system which is in equilibrium and there is equity of provision across socioeconomic scales; it must be both fit for purpose, and meet the needs of the local population, demonstrating that people are at the heart of the service, proposed service redesign and development.
Pain management is best delivered by multidisciplinary and multiprofessional teams; the composition of such teams will be driven by the local needs of the population and the professionals available with the competencies to work within pain management, however, integrated primary and secondary care pain management services are increasingly seen as an optimal model of care in the evolving NHS.
Pain management treatment pathways should be based around evidence based pathways such as the British Pain Society’s Map of Medicine Pain Pathways3.
There is no intention to impose a ‘one size fits all’ approach to the management of pain, but rather to provide an opportunity for providers and commissioners to work together at a local level, to ensure that key services and management approaches are appropriately commissioned.
The Faculty of Pain Medicine has published recommendations for staffing and resources for Specialist Pain Management Services to aid clinicians in their discussions with Commissioners4.
The Royal College of General Practitioners in conjunction with the Faculty of Pain Medicine, the British Pain Society, the Chronic Pain Policy Coalition and individual professional and lay advisers has published a document to help engagement and enhance discussions between health care professionals and commissioners when designing pain management services5.
Specialised Pain Management Services
NHS England is directly responsible for commissioning Prescribed Specialised Services6with the aim of ensuring that services, for those individuals that require specialised care, are of a high quality and consistent across England.
The scope of the services considered as specialised is being reviewed on a regular basis. Specialised Pain Management Services are still in scope for 2015 and are defined by the Service Specification D087. This document was written by the Clinical Reference Group for Specialised Pain Service – Adult (CRG-SPS).
The CRG-SPS is chaired by a leading Pain Medicine clinician, has representation by Senate Regional Pain Medicine Specialists, The Faculty of Pain Medicine, The British Pain Society and other Specialist Societies and as well as patient and carer input.
The Service Specification D08, clearly outlines the groups of pain patients, the interventions and the characteristics of those services that are considered Specialised. It is the role of the Local Area Team commissionaires to ensure that those services are commissioned and that the standards are maintained.
Most pain patients will be managed by local community and speciality pain management services. Only a small,but significant number will be referred to Specialised Regional Centres. Currently the number of Specialised Centres meeting the Service Specification is small and in the long term, restructuring and financial investment may be required.